Old Age: The New Demography

In this week’s issue, Atul Gawande discusses the complex medical, emotional, and financial issues surrounding end-of-life care. (Gawande also participated in a live chat on the subject yesterday.) In his piece, Gawande notes how the process of dying has changed as medicine has advanced:

For all but our most recent history, dying was typically a brief process. Whether the cause was childhood infection, difficult childbirth, heart attack, or pneumonia, the interval between recognizing that you had a life-threatening ailment and death was often just a matter of days or weeks….

These days, swift catastrophic illness is the exception; for most people, death comes only after long medical struggle with an incurable condition—advanced cancer, progressive organ failure (usually the heart, kidney, or liver), or the multiple debilities of very old age.

Aging and the care of the elderly were the subjects of Gawande’s article “The Way We Age Now,” published in the issue of April 30, 2007. That article can be read as a kind of companion piece to his current one. In it he describes the work of geriatricians—physicians who specialize in the needs of the elderly—and also considers the demands placed on society by a population with ever-increasing life expectancy:

Throughout most of human history, a society’s population formed a sort of pyramid: young children represented the largest portion—the base—and each successively older cohort represented a smaller and smaller group. In 1950, children under the age of five were eleven per cent of the U.S. population, adults aged forty-five to forty-nine were six per cent, and those over eighty were one per cent. Today, we have as many fifty-year-olds as five-year-olds. In thirty years, there will be as many people over eighty as there are under five.

Americans haven’t come to grips with the new demography. We cling to the notion of retirement at sixty-five—a reasonable notion when those over sixty-five were a tiny percentage of the population, but completely untenable as they approach twenty per cent. People are putting aside less in savings for old age now than they have in any decade since the Great Depression. More than half of the very old now live without a spouse, and we have fewer children than ever before—yet we give virtually no thought to how we will live out our later years alone.

Equally worrying, and far less recognized, medicine has been slow to confront the very changes that it has been responsible for—or to apply the knowledge we already have about how to make old age better. Despite a rapidly growing elderly population, the number of certified geriatricians fell by a third between 1998 and 2004. Applications to training programs in adult primary-care medicine are plummeting, while fields like plastic surgery and radiology receive applications in record numbers. Partly, this has to do with money—incomes in geriatrics and adult primary care are among the lowest in medicine. And partly, whether we admit it or not, most doctors don’t like taking care of the elderly.